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www.elsevier.com/locate/jpedsurg
Fracture of the occipital condyle caused byminor trauma in child
Thomas Kapapaa,*, Christoph A. Tschanb, Kathrin Konigb, Arkadius Schlesingerc,Bernd Haubitzc, Hartmut Beckerc, Matthias Zumkellerd, Rickels Eckharda
aDepartment of Neurosurgery, University Ulm, 89070 Ulm, GermanybDepartment of Neurosurgery, Medizinische Hochschule Hannover, 30625 Hannover, GermanycDepartment of Neuroradiology, Medizinische Hochschule Hannover, 30625 Hannover, GermanydDepartment of Neurosurgery, Klinikum Minden, 32427 Minden, Germany
0022-3468/$ – see front matter D 2006
doi:10.1016/j.jpedsurg.2006.05.036
* Corresponding author. Neurochir
Universit7tsklinikum Ulm, 89075 Ulm, G
fax: +49 731 50041969.
E-mail address: thomas.kapapa@uni
Index words:Fracture of
occipital condyle;
Whiplash injury;
Neck pain;
Spinal injuries;
Head trauma
Abstract We report a case of fractured occipital condyle caused by minor trauma accompanied by light
pain on palpation at the lateral cervical trigonum. A 15-year-old boy complained of nuchal pain,
particularly pain on palpation at the left lateral cervical trigonum in the absence of neurologic deficits
after head deceleration trauma. Computed tomography demonstrated a unilateral nonluxated fracture of
the occipital condyle. Owing to consequent immobilization by means of cervical orthosis, pain
disappeared after the first 48 hours. Follow-up examination 4 weeks later showed no neurologic deficits.
The boy had no severe impairment of movements at the cervical spine.
D 2006 Elsevier Inc. All rights reserved.
The presence of an occipital condyle fracture after head
injury is seldom seen, especially when diagnosed in the
absence of neurologic deficits, or even worse, if it is
presented in childhood with nonspecific complaints.
1. Patient and method
A 15-year-old boy was playing on a carousel with his
classmates in the schoolyard. While driving around, he lost
hold and hit sandy ground with the left side of his head.
Trauma was reported as an axial torsion movement. At the
scene of the accident, the boy had his cervical spine
Elsevier Inc. All rights reserved.
urgische Klinik, Albert-Einstein-
ermany. Tel.: +49 731 50041951;
klinik-ulm.de (T. Kapapa).
immobilized by a stiff-neck collar (Laerdal Medical GmbH
& Puchheim, Germany). No initial loss of consciousness or
signs of neurologic deficits were observed. At the emergency
department, the boy reported a progressive pain in the neck as
well as at the left cervical trigonum after palpation. He kept
his head in a fixed position. Subsequent neurologic exami-
nation showed no abnormalities. Computed cranial tomog-
raphy (CT) excluded intracranial signs of trauma. An axial
spiral CTscan (1.25-mm slice thickness) with high-resolution
algorithm gave hints of irregularity of the craniocervical
junction. Two-dimensional reformation of the craniocervical
junction and the remaining cervical spine showed a fracture
of the left occipital condyle without dislocation of the
fragment (Figs. 1 and 2). The medulla was not affected.
Hence, there was no need for acute neurosurgical interven-
tion. After being provided with a rigid collar, the boy was
given light pain medication and was monitored under clinical
conditions. Pain medication was discontinued after 48 hours.
Journal of Pediatric Surgery (2006) 41, 1774–1776
Fig. 1 Computed tomogram showing a fracture of the occipital
condyle at the left side.
Table 1 Classification of condylus occipitalis fractures by
Anderson and Montesano [12]
Fracture
type
Fracture Stability
1 Impacted condyle with
comminution, no displacement into
the foramen magnum
Stable
2 Basal skull fracture with extension
into the occipital condyle without
any displacement
Stable
3 Avulsion fracture with injury
of the ligamentum alare
Potentially
stable
Fracture of the occipital condyle caused by minor trauma in child 1775
The young patient was discharged after 5 days without
any neurologic signs and was prescribed the cervical Miami
J Collar for 4 more weeks.
At follow-up examination 4 weeks later, the boy was still
in good condition without any deficits. Pain in the neck
occurred intermittently after mindless movements and
disappeared fast. A CT scan showed a reorganization of
fracture fragments. We decided to remove the orthosis.
2. Discussion
Fracture of the occipital condyle is often reported to be
an unusual lesion compared with other described injuries of
Fig. 2 Computed tomogram excluding affecting of the medulla
by fractured parts of the left condyle.
the human spine. An incidence of 4.2% was found in
autopsies of fatal traffic accident victims [1]. The first cases
reported in the literature had major head trauma with
impaired consciousness, and most cases had major trauma
[1-5]. Numbers of reported cases increased with advances in
CT imaging and awareness of their existence [6].
The clinical presentations vary from absence of neuro-
logic deficits to lower cranial nerve palsies. These palsies
could be with delayed presentation [7]. This is one of the
reasons why this potentially lethal fracture could be missed.
Standard radiographic examinations after admission into the
emergency department are important in the management of
spine injury but have considerable limitations in these cases.
High-resolution CT is the only method to exclude this
fracture definitely. Especially, reformatted 2-dimensional
CT may show this fracture in childhood even when points of
growth joints appear unfinished.
In most cases, patients were older than 21 years. Hence,
we lack information concerning the presence of occipital
condyle fracture in children or in adolescent patients. There
are some cases reported in younger patients who were also
involved in severe accidents like older persons [2,5,6,8-11].
Very little is reported about younger subjects and minor
traumas that can cause an occipital condyle fracture. Indeed,
falling from a donkey or from a carousel is a trauma, but com-
pared with a high-energy accident, it has a lower grade of
power of impact [6]. Regarding the rare cases of young vic-
tims with minor trauma and the trauma mechanism, fracture
of the occipital condyle could occurmore often than expected.
In our case, the young boy had no neurologic deficits.
Based on the classification of Anderson and Montesano, this
fracture is categorized as type I (Table 1) [12]. It is an
impacted condyle fracture with comminution, but without
displacement into the foramen magnum. Anderson and
Montesano considered this sort of fracture to be stable. The
mechanism of injury was believed to be axial loading. These
considerations agree with our case.
3. Conclusion
In case of unexplained posttraumatic neck pain, espe-
cially in the absence of neurologic deficits and nonspecific
T. Kapapa et al.1776
complaints, the craniocervical junction should be assessed
by CT scan even in young patients with minor trauma.
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